A Guide. Laparoscopic Pelvic Lymph Node Dissection UROLOGIC

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1 UROLOGIC L i m i t e d Laparoscopic Pelvic Lymph Node Dissection A Guide for Patients Rotorua Michael D. Cresswell F.R.A.C.S (Urol) Tauranga Mark R. Fraundorfer F.R.A.C.S (Urol) Peter J. Gilling F.R.A.C.S (Urol) Andre M. Westenberg F.R.A.C.S (Urol) PO Box 893, Tauranga, New Zealand, Phone: / , Fax: Hamilton Patrick R. Bary F.R.A.C.S (Urol) Michael A. Holmes F.R.A.C.S (Urol) William L. Wright F.R.A.C.S (Urol) PO Box 19210, Hamilton, New Zealand, Phone: / , Fax: Text Compiled by: Angela Hewitt RCN Urology Nurse Specialist Copyright 2001

2 LAPAROSCOPIC PELVIC LYMPH NODE DISSECTION This information is designed to help you, your family and friends prepare for your surgery. It will also help you plan how to take care of yourself in the weeks following your discharge from hospital. WHAT IS A LAPAROSCOPIC PELVIC LYMPH NODE DISSECTION? A Laparoscopic Pelvic Lymph Node Dissection (L.P.L.N.D) is the removal of the pelvic lymph nodes, using key-hole surgery, through five small incisions made in the abdomen. The lymphatic system is one of the body s natural defenses. It is made up of lymph vessels that contain lymphatic fluid, a nearly clear fluid that carries waste from the cells of the body to the lymph nodes, which act like filters, filtering unwanted substances. The pelvic lymph nodes are the first port-of-call for the cancer cells as they exit from the prostate gland through the lymphatic system. A B The L.P.L.N.D removes the lymph nodes in the pelvis by using laparoscopic equipment. Long thin instruments are passed through five small incisions made on the abdomen, these are known as ports, (Fig. 1). There is one port just below the umbilicus (your belly button), and two on either side of the lower abdomen, each is about 1cm in length. Through these ports the laparoscopic equipment is passed. The abdomen is first filled with carbon dioxide air, which separates the tissues to allow for vision during the surgery. A camera is passed through the laparoscopic equipment and its images are watched on a television screen, giving the Urologist a full picture inside the abdomen. The other ports are used to pass cutting and cauterising instruments so the lymph nodes can be removed and any bleeding points can be sealed. When the operation is finished the carbon dioxide air is removed from the abdomen and the cuts are stitched closed with dissolving stitches. The areas are then covered with small plasters. The lymph nodes are sent to the laboratory for analysis and reporting so further treatment decisions can then be made.

3 WHY IS A L.P.L.N.D. NEEDED? This operation is for men with prostate cancer and gives further information about any spread of the disease. By removing the pelvic lymph nodes your specialist is able to determine whether or not there has been any spread of the cancer out of the prostate gland. This information is used to help determine the appropriate treatment for you. If there is no cancer in the lymph glands either radiation treatment or surgical removal of the prostate gland may be undertaken. However, if the cancer has spread to the lymph glands the best treatment option may be hormonal therapy to stabilise the disease and help delay further spread. YOUR CONSENT We need your permission for your operation to go ahead. Before you sign the consent form it is important that you understand the risks and effects of the operation and anaesthetic. These will be discussed with you by your doctor and the nurse, should you have any questions, your nurse or doctor would be happy to answer these. It would be a very rare occurrence to require a blood transfusion with this surgery. However, in the unusual event that you did need a blood transfusion and you want to refuse one, it is vital that you tell your surgeon and nurse prior to your operation. ABOUT YOUR ANAESTHETIC You will NOT be allowed to eat or drink anything for at least six hours before your surgery. This includes chewing gum and sweets. There are two main types of anaesthetic used for this surgery; General Anaesthetic: You will be asleep throughout the operation and remember nothing of it. (A general anaesthetic is almost always used during laparoscopic surgery). Regional Anaesthetic e.g. Spinal, Epidural or Caudal: A needle is placed into your back and a solution is injected that will numb your body from the waist down. You will be awake but may be sleepy and you will not feel the operation. Feel free to discuss these options, and your questions with the anaesthetist. You must not drive any vehicle or operate any machinery for 24 hours after having an anaesthetic. You will have to arrange for someone to drive you home if you go home within 24 hours of your surgery. YOUR OPERATION On admission you will be informed of an approximate operation time and prepared for theatre by your nurse. You maybe fitted with T.E.D. stockings which help aid circulation and prevent blood clots which there is always a slight risk of with abdominal surgery. You may also be instructed about special deep breathing and leg exercises which you should do after surgery. A shave of the surgical site is required, this is usually done just prior to going to theatre or in theatre itself once you are asleep.

4 You may be given some tablets before theatre. These are charted by your anaesthetist and may include tablets for tension, nausea and pain prevention. You will be escorted on your bed to the theatre waiting room and then to the theatre itself, where you will be transferred to the theatre table. Anaesthetic staff will then insert a drip in your arm and attach various monitoring devices. Once you have been completely prepared and given your anaesthetic, surgery will begin. The operation takes approximately two hours to complete. However, in the unlikely event of an equipment failure or unexpected complication a larger incision may need to be made to complete surgery and this may alter the surgery time. When the operation is completed you will go to the recovery room for a short while where you will be cared for until you are ready to be transferred to the ward. AFTER SURGERY Your nurse will check your blood pressure, pulse and temperature routinely. Your abdomen and the port sites will be checked for any bleeding and your urine output will be monitored. You will have a drip in your arm to make sure you receive adequate fluids. This will be removed once you are drinking normally. You can usually drink when you return to the ward and you may eat once you are tolerating fluids. You will have a urinary catheter in. This is a drainage tube that passes up the penis into the bladder and drains your urine into a bag. The catheter is held in place inside the bladder by a small balloon so that it can t slip out. Once you have recovered from your anaesthetic your nurse will help you to get out of bed for the first time. If you have had a spinal anaesthetic you may be asked to lie flat for several hours after returning to the ward to allow for the anaesthetic to wear off. After surgery there is a chance that you may experience some discomfort at the tip of your shoulder. Sometimes the carbon dioxide can spread under the skin for a small distance during surgery which is of no concern. However, if the remaining carbon dioxide irritates the diaphragm this can effect the nerves that supply the shoulder and cause shoulder tip pain. This is nothing to be concerned about, the pain can be relieved with medication and goes once the body has absorbed the carbon dioxide. Bruising can occasionally occur beneath the skin. This resolves by itself but may cause some alarm when first seen if it does cover a larger area of the abdomen. Our aim is to keep you as comfortable as possible, it is important that the nurse knows when the pain or discomfort starts so your symptoms can be relieved as quickly and easily as possible. At all times, your nurse is there to help you, please ring your bell if you need assistance and your nurse is not nearby. ON THE DAY FOLLOWING THE OPERATION: Your catheter is removed in the morning. The balloon of the catheter is deflated by using a special device located at the end of the catheter where it connects to the drainage bag. The catheter slides out easily once the balloon is deflated causing little discomfort. When the catheter is removed you will be asked to pass your urine into a urine bottle so the amount can be monitored. Once the catheter comes out you may have a burning sensation when passing your urine. This is because urine is naturally acidic and when it is passed after the catheter is removed, any area within the urethra that has been irritated from having the catheter in is effected. If this happens please tell your nurse who will be able to give you some medication to neutralise your urine and relieve the burning. Once your catheter has been removed you will be able to get up for a shower. If the

5 plasters are not waterproof your nurse will replace them after your shower with waterproof ones which you will be asked to remove at home. GOING HOME Once you are catheter free, eating and drinking and you have passed urine you will be able to go home. This is usually by mid morning the day after your surgery. Before leaving the ward you will be given a discharge information letter which contains helpful information for when you get home. You will be given or sent an outpatient appointment which is usually 4-6 weeks after your operation. We will send a letter to your own doctor about your operation and the details of your treatment while you were in hospital. ONCE HOME Before discharge your nurse will inform you about taking mild pain relievers, should you have any pain or discomfort after you return home. The internal healing after surgery takes 3-4 weeks. During this time you should avoid any heavy lifting, straining or strenuous activity. Apart from strenuous activities you will be able to continue with your normal daily routines, as you feel able. Your waterproof plasters are to stay in place for 3 days. If moisture does get underneath the plasters before the three days are up then they should be removed. Under the plasters there maybe small strips of tape (steri-strips) which act like a skin stitch to help with healing. If these start to peel off they can be removed. If they do not peel away by themselves they should be removed on the 5th day after surgery. Once the original plasters have been removed you should wash your wounds with water only, no soap is to be used directly on your wounds until they have healed completely. The wounds are usually dry within 48 hours of surgery. If they become reddened, swollen or painful or the ooze persists, you should contact your own doctor as soon as possible as these are signs of a wound infection. After a L.P.L.N.D. there is a very slight chance of developing a lymphocele which is a collection of lymph fluid within the abdomen. In most cases lymphoceles need no treatment as the body reabsorbs the fluid collection over time. However, if the collection persists or enlarges, simple drainage may be necessary. If you experience an abnormal swelling of the abdomen along with a feeling of pain or pressure you should contact your own doctor for further advice. This is routinely a straight forward operation, after which most patients have a speedy recovery and experience little pain. While you are in hospital we will do everything we can to make your stay as comfortable as possible. The nursing and medical staff are always available to help with whatever needs you have. If you are worried about anything before or after your surgery, or if you have any further questions or would like more information, please do not hesitate to ask your nurse who will be more than happy to help.